About You

INFORMED CONSENT FOR THERAPEUTIC ARTS PRACTICE SESSIONS (child

I, informed by the following, agree and consent to participate in Therapeutic Arts Practice with Louise Kent

Therapeutic Arts Practice provides opportunities for individuals to give voice to that which is not easily expressed with words. Therapeutic Arts Practice often helps people to develop their understanding of themselves and their patterns of behaviour in relation to others.

Therapeutic Arts Practice is not diagnostic. The focus is on gaining awareness and deepening understanding, then using these to identify strengths and develop strategies to apply to life, relationships, and challenges.

I understand that all information gathered by Louise during intake or therapy is confidential except within the following circumstances:

• You agree to Louise sharing information with a third party 

• It is subpoenaed by a court

• Louise becomes aware of any serious risk to self or others.

Consent can be revoked by you in writing at any time. If you have any need to contact me, please email louisekenttap@gmail.com.

Date

Guardian Name

Student Name

Guardian Phone

Allergies?

Yes  /  No

Guardian Email

If yes, what allergies? 

☐ Cancellations made within 24 hours of appointment time will be charged at the full rate.

I have read and agree to the all of the above. Client signature (parent/guardian of a minor) 

_________________________________________________    Date ______________